EMDR Therapy

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What is EMDR Therapy?

Treatment Description

EMDR combines different elements of many effective therapies to maximize treatment effects. EMDR uses a procedure that reduces the intensity of the traumatic images. This process reduces the emotional response to the disturbing memories. A full description of the theory, sequence of treatment, and research on protocols and active mechanisms can be found in F. Shapiro (2001) Eye movement desensitization and reprocessing: Basic principles, protocols and procedures (2nd edition) New York: Guilford Press.

EMDR does not require detailed descriptions of the trauma. EMDR also does not require fixed concentration on the event. It only requires in-session time for treatment. Homework in EMDR usually consists of the client writing down any problems he or she has between sessions and using a relaxation technique if needed.

EMDR involves attention to three time periods: the past, present, and future. Focus is given to past disturbing memories and related events. It is also given to current situations that cause distress. Attention also is given to developing the skills and attitudes needed for positive future actions. With EMDR, these items are addressed using an eight-phase treatment approach. The first phase is a history-taking session. The therapist assesses the client’s readiness for EMDR and develops a treatment plan. Client and therapist identify possible targets for EMDR processing. These include distressing memories and current situations that cause emotional distress. Other targets may include related incidents in the past. Emphasis is placed on the development of specific skills and behaviors that will be needed by the client in future situations. Initial EMDR processing may be directed to childhood events rather than to adult onset stressors or the identified critical incident if the client had a problematic childhood. Clients generally gain insight on their situations. They then may start to change their behaviors. The length of treatment depends upon the number of traumas and the age of PTSD onset. Generally, those with single event adult onset trauma can be successfully treated in under 5 hours. Multiple trauma victims may require a longer treatment time.

During the second phase of treatment, the therapist ensures that the client has several different ways of handing emotional distress. The therapist may teach the client a variety of imagery techniques the client can use during and between sessions.
In phases three through six, a target is identified and processed using EMDR procedures. These involve the client identifying three things:

1. The vivid visual image related to the memory.
2. A negative belief about self.
3. Related emotions and body sensations.

The client also identifies a positive belief. The therapist helps the client rate the positive belief as well as the intensity of the negative emotions. After this, the client is instructed to focus on the image, negative thought, and body sensations, while simultaneously engaging in an EMDR behavior. This behavior may include eye movements, taps, or tones. The type and length of these behaviors is different for each client. At this point, the EMDR client is instructed to just notice whatever spontaneously happens. After each set of EMDR behaviors, the clinician instructs the client to let his/her mind go blank and to notice whatever thought, feeling, image, memory, or sensation comes to mind. Depending upon the client’s report, the clinician will choose the next focus of attention. In most cases, the client is encouraged to direct where the focus goes next. This is repeated numerous times throughout the session. If the client becomes distressed or has difficulty in progressing, the therapist follows established procedures to help the client get back on track.

When the client reports no distress related to the targeted memory, s/he is asked to think of the preferred positive belief that was identified at the beginning of the session. The client then may adjust the positive belief if necessary, and then focus on it during the next set of distressing events. Clients generally report increased confidence in the positive belief over time. The therapist checks with the client regarding body sensations. If there are negative sensations, these are processed as above.

In phase seven, closure, the therapist asks the client to keep a journal during the week. The journal should document any related material that may arise. It also serves to remind the client of the self- calming activities that were mastered in phase two. The next session begins with phase eight. Phase eight consists of examining the progress made thus far. The EMDR treatment processes all related historical events, current incidents that elicit distress, and future events that will require different responses.

Francine Shapiro, Ph.D. is a senior research fellow at the Mental Research Institute. She also is the founder and President Emeritus of the EMDR Humanitarian Assistance Programs, a nonprofit organization that coordinates disaster response and pro bono trainings worldwide. Dr. Shapiro was designated as one of the “Cadre of Experts” of the American Psychological Association & Canadian Psychological Association Joint Initiative on Ethnopolitical Warfare, and has served as advisor to numerous trauma treatment and outreach organizations. She has written three books about EMDR: Eye Movement Desensitization and Reprocessing (Guilford Press), EMDR (BasicBooks), and EMDR as an Integrative Psychotherapy Approach (American Psychological Association Press). She is a recipient of the International Sigmund Freud Award of the City of Vienna, for distinguished contribution to psychotherapy, and the Distinguished Scientific Achievement in Psychology Award presented by the California Psychological Association.

What is the actual EMDR session like?

Eye Movement Desensitization and Reprocessing (EMDR) is an integrative psychotherapy approach that has been extensively researched and proven effective for the treatment of trauma. EMDR is a set of standardized protocols that incorporates elements from many different treatment approaches. To date, EMDR therapy has helped millions of people of all ages relieve many types of psychological stress. Below is a Brief Description of EMDR Therapy.

Eight Phases of Treatment

The amount of time the complete treatment will take depends upon the history of the client. Complete treatment of the targets involves a three pronged protocol (1-past memories, 2-present disturbance, 3- future actions), and are needed to alleviate the symptoms and address the complete clinical picture. The goal of EMDR therapy is to process completely the experiences that are causing problems, and to include new ones that are needed for full health. “Processing” does not mean talking about it. “Processing” means setting up a learning state that will allow experiences that are causing problems to be “digested” and stored appropriately in your brain. That means that what is useful to you from an experience will be learned, and stored with appropriate emotions in your brain, and be able to guide you in positive ways in the future. The inappropriate emotions, beliefs, and body sensations will be discarded. Negative emotions, feelings and behaviors are generally caused by unresolved earlier experiences that are pushing you in the wrong directions. The goal of EMDR therapy is to leave you with the emotions, understanding, and perspectives that will lead to healthy and useful behaviors and interactions.

Phase 1: History and Treatment Planning

Generally takes 1-2 sessions at the beginning of therapy, and can continue throughout the therapy, especially if new problems are revealed. In the first phase of EMDR treatment, the therapist takes a thorough history of the client and develops a treatment plan. This phase will include a discussion of the specific problem that has brought him into therapy, his behaviors stemming from that problem, and his symptoms. With this information, the therapist will develop a treatment plan that defines the specific targets on which to use EMDR. These targets include the event(s) from the past that created the problem, the present situations that cause distress, and the key skills or behaviors the client needs to learn for his future well-being. One of the unusual features of EMDR is that the person seeking treatment does not have to discuss any of his disturbing memories in detail. So while some individuals are comfortable, and even prefer, giving specifics, other people may present more of a general picture or outline. When the therapist asks, for example, “What event do you remember that made you feel worthless and useless?” the person may say, “It was something my brother did to me.” That is all the information the therapist needs to identify and target the event with EMDR.

Phase 2: Preparation

For most clients this will take only 1-4 sessions. For others, with a very traumatized background, or with certain diagnoses, a longer time may be necessary. Basically, your clinician will teach you some specific techniques so you can rapidly deal with any emotional disturbance that may arise. If you can do that, you are generally able to proceed to the next phase. One of the primary goals of the preparation phase is to establish a relationship of trust between the client and the therapist. While the person does not have to go into great detail about his disturbing memories, if the EMDR client does not trust his clinician, he may not accurately report what he feels and what changes he is (or isn’t) experiencing during the eye movements. If he just wants to please the clinician and says he feels better when he doesn’t, no therapy in the world will resolve his trauma. In any form of therapy it is best to look at the clinician as a facilitator, or guide, who needs to hear of any hurt, need, or disappointments in order to help achieve the common goal. EMDR is a great deal more than just eye movements, and the clinician needs to know when to employ any of the needed procedures to keep the processing going. During the Preparation Phase, the clinician will explain the theory of EMDR, how it is done, and what the person can expect during and after treatment. Finally, the clinician will teach the client a variety of relaxation techniques for calming himself in the face of any emotional disturbance that may arise during or after a session. Learning these tools is an important aid for anyone. The happiest people on the planet have ways of relaxing themselves and decompressing from life’s inevitable, and often unsuspected, stress. One goal of EMDR therapy is to make sure that the client can take care of himself.

Phase 3: Assessment

Used to access each target in a controlled and standardized way so it can be effectively processed. Processing does not mean talking about it. See the Reprocessing sections below. The clinician identifies the aspects of the target to be processed. The first step is for the person to select a specific picture or scene from the target event (which was identified during Phase One) that best represents the memory. Then he chooses a statement that expresses a negative self-belief associated with the event. Even if he intellectually knows that the statement is false, it is important that he focus on it. These negative beliefs are actually verbalizations of the disturbing emotions that still exist. Common negative cognitions include statements such as “I am helpless,” ” I am worthless,” ” I am unlovable,” ” I am dirty,” ” I am bad,” etc. The client then picks a positive self-statement that he would rather believe. This statement should incorporate an internal sense of control such as “I am worthwhile/ lovable/ a good person/ in control” or “I can succeed.” Sometimes, when the primary emotion is fear, such as in the aftermath of a natural disaster, the negative cognition can be, “I am in danger” and the positive cognition can be, “I am safe now.” “I am in danger” can be considered a negative cognition, because the fear is inappropriate — it is locked in the nervous system, but the danger is actually past. The positive cognition should reflect what is actually appropriate in the present. At this point, the therapist will ask the person to estimate how true he feels his positive belief is using the 1-to-7 Validity of Cognition (VOC) scale. “1” equals “completely false,” and ” 7″ equals “completely true.” It is important to give a score that reflects how the person “feels,” not ” thinks.” We may logically ” know” that something is wrong, but we are most driven by how it ” feels.” Also, during the Assessment Phase, the person identifies the negative emotions (fear, anger) and physical sensations (tightness in the stomach, cold hands) he associates with the target. The client also rates the disturbance using the 0 (no disturbance)-to-10 (the worst feeling you? ve ever had) Subjective Units of Disturbance (SUD) scale. Reprocessing For a single trauma reprocessing is generally accomplished within 3 sessions. If it takes longer, you should see some improvement within that amount of time. Phases One through Three lay the groundwork for the comprehensive treatment and reprocessing of the specific targeted events. Although the eye movements (or taps, or tones) are used during the following three phases, they are only one component of a complex therapy. The use of the step-by-step eight-phase approach allows the experienced, trained EMDR clinician to maximize the treatment effects for the client in a logical and standardized fashion. It also allows both the client and the clinician to monitor the progress during every treatment session.

Phase 4: Desensitization

This phase focuses on the client’s disturbing emotions and sensations as they are measured by the SUDs rating. This phase deals with all of the person’s responses (including other memories, insights and associations that may arise) as the targeted event changes and its disturbing elements are resolved. This phase gives the opportunity to identify and resolve similar events that may have occurred and are associated with the target. That way, a client can actually surpass her initial goals and heal beyond her expectations. During desensitization, the therapist leads the person in sets of eye movement (or other forms of stimulation) with appropriate shifts and changes of focus until his SUD-scale levels are reduced to zero (or 1 or 2 if this is more appropriate). Starting with the main target, the different associations to the memory are followed. For instance, a person may start with a horrific event and soon have other associations to it. The clinician will guide the client to a complete resolution of the target. Examples of sessions and a three-session transcript of a complete treatment can be found in F. Shapiro & M.S. Forrest (2004) EMDR. New York: BasicBooks. http://www.perseusbooksgroup.com/perseus-cgi-bin/display/ 0-465-04301-1

Phase 5: Installation

The goal is to concentrate on and increase the strength of the positive belief that the person has identified to replace his original negative belief. For example, the client might begin with a mental image of being beaten up by his father and a negative belief of “I am powerless.” During the Desensitization Phase he will have reprocessed the terror of that childhood event and fully realized that as an adult he now has

strength and choices he didn’t have when he was young. During this fifth phase of treatment, his positive cognition, “I am now in control,” will be strengthened and installed. How deeply the person believes his positive cognition is then measured using the Validity of Cognition (VOC) scale. The goal is for the person to accept the full truth of his positive self-statement at a level of 7 (completely true). Fortunately, just as EMDR cannot make anyone shed appropriate negative feelings, it cannot make the person believe anything positive that is not appropriate either. So if the person is aware that he actually needs to learn some new skill, such as self-defense training, in order to be truly in control of the situation, the validity of his positive belief will rise only to the corresponding level, such as a 5 or 6 on the VOC scale.

Phase 6: Body scan

After the positive cognition has been strengthened and installed, the therapist will ask the person to bring the original target event to mind and see if he notices any residual tension in his body. If so, these physical sensations are then targeted for reprocessing. Evaluations of thousands of EMDR sessions indicate that there is a physical response to unresolved thoughts. This finding has been supported by independent studies of memory indicating that when a person is negatively affected by trauma, information about the traumatic event is stored in motoric (or body systems) memory, rather than narrative memory, and retains the negative emotions and physical sensations of the original event. When that information is processed, however, it can then move to narrative (or verbalizable) memory and the body sensations and negative feelings associated with it disappear. Therefore, an EMDR session is not considered successful until the client can bring up the original target without feeling any body tension. Positive self-beliefs are important, but they have to be believed on more than just an intellectual level.

Phase 7: Closure

Ends every treatment session The Closure ensures that the person leaves at the end of each session feeling better than at the beginning. If the processing of the traumatic target event is not complete in a single session, the therapist will assist the person in using a variety of self-calming techniques in order to regain a sense of equilibrium. Throughout the EMDR session, the client has been in control (for instance, he is instructed that it is okay to raise his hand in the “stop” gesture at anytime) and it is important that the client continue to feel in control outside the therapist’s office. He is also briefed on what to expect between sessions (some processing may continue, some new material may arise), how to use a journal to record these experiences, and which techniques he might use on his own to help him feel more calm.

Phase 8: Reevaluation

Opens every new session At the beginning of subsequent sessions, the therapist checks to make sure that the positive results (low SUDs, high VOC, no body tension) have been maintained, identifies any new areas that need treatment, and continues reprocessing the additional targets. The Reevaluation Phase guides the clinician through the treatment plans that are needed in order to deal with the client’s problems. As with any form of good therapy, the Reevaluation Phase is vital in order to determine the success of the treatment over time. Although clients may feel relief almost immediately with EMDR, it is as important to complete the eight phases of treatment, as it is to complete an entire course of treatment with antibiotics.

Past, Present and Future

Although EMDR may produce results more rapidly than previous forms of therapy, speed is not the issue and it is important to remember that every client has different needs. For instance, one client may take weeks to establish sufficient feelings of trust (Phase Two), while another may proceed quickly through the first six phases of treatment only to reveal, then, something even more important that needs treatment. Also, treatment is not complete until EMDR therapy has focused on the past memories that are contributing to the problem, the present situations that are disturbing, and what skills the client may need for the future. Excerpts from: F. Shapiro & M.S. Forrest (2004) EMDR: The Breakthrough Therapy for Anxiety, Stress and Trauma. New York: BasicBooks. http://www.perseusbooksgroup.com/perseus-cgi-bin/ display/0-465-04301-1. http://www.therapyadvisor.com/LocalContent/adult/consumer-shapiro-EMDR-ptsd.pdf

For further information, log onto:

http://emdr.com/

http://www.emdria.org/?

http://www.emdrhap.org/?

Books:

EMDR: The Breakthrough “Eye Movement” Therapy for Overcoming Anxiety, Stress, and Trauma by Francine Shapiro and Margot Silk Forrest.

Getting Past Your Past by Francine Shapiro.